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New ICH stroke treatment saves a life by Heather Woolwine Public Relations When Jannia Myers, 49, went to work around 7 o’clock on Feb. 19, she felt a little funny. She recalled a slow-moving state of mind, like she was just having a hard time functioning. Myers didn’t know that a golf-ball size blood clot in her brain was about to alter her life forever, or that a revolutionary stroke treatment study at MUSC would bring her back from death’s door. Morbidity and mortality As Myers tried to set about her usual duties as a cashier in a local gas station and convenience store in Orangeburg, things did not get better. Instead, they became much worse. “My head was hurting so bad,” Myers said. “I told my assistant manager that she better call my husband. Later on, she told me that she was pretty sure I was having a stroke.” Myers' husband, Jacob, said he figured everything would be all right once the ambulance arrived. But, then, at the hospital Myers had another stroke. “She went into convulsions, and I could see the flat lines going across the screens,” he said. “They had to hit her with a charge to bring her back. They told us that the scans were showing a huge clot in her brain, and by 11 (p.m.) she was on the helicopter to MUSC.”   Jannia Myers awaits the beginning of an MRI to determine how much her brain tissue has healed since her stroke.   Jacob raced to meet his wife at the hospital. As MUSC doctors, a clinical pharmacist and a research nurse evaluated Myers' case, the possibilities of her survival or good quality of life post-stroke were slim. Myers suffered from an intracranial hemorrhagic (ICH) stroke, which accounts for 10 percent of all stroke patients. MUSC is the only hospital in the southeast that can treat this particular kind of stroke with novel therapies endorsed by the National Institutes of Health (NIH).   Along with hemorrhagic stroke comes an 85 percent morbidity or mortality rating—meaning that most patients will either die or become severely disabled and dependent following their stroke compared to 35 percent for ischemic stroke . As the odds mounted and more precious time passed, Byron Bailey, M.D., Neurosurgery, Suhas Pai, M.D., Neurosurgery, Marc Lapointe, Pharm.D., Pharmacy and Clinical Sciences, and Bonnie Muntz-Pope R.N., Neurosurgery, decided to see if Myers would be eligible for an NIH clinical trial pertaining to stroke treatment.   Called the MISTIE study (Minimally Invasive Surgery plus tPA for ICH Evaluation), clinicians involved in this national multi-center study are determining more effective means of treating ICH. Traditionally, physicians and surgeons have two choices: wait and see what the clot does on its own (a process that can last anywhere from 14 to 21 days as pieces of the clot slowly break off) or perform surgery to remove the clot. The more time that passes, the more damage caused to parts of the brain necessary for motor skills, talking and critical thought. Shockingly, research has discovered that neither approach is very effective in terms of patient recovery or improving their quality of life post-stroke.   Images from the one-month post-stroke MRI show that while Myers has some residual scarring related to her blood clot, her brain has been able to heal with the help of revolutionary stroke treatment.   For the nine U.S. centers conducting the study, discovering the effectiveness of a new method of treating this type of stroke is the goal in improving morbidity and mortality for these stroke patients. “I think the collective idea is that we don’t have anything to lose by thinking more specifically in terms of minimally invasive surgical interventions and then removing blood clots faster with tPA,”  Lapointe said. TPA or tissue plasminagin activator is a clot-dissolving medicine featured in this study.   In the study, patients such as Myers receive 3-D imaging of the brain prior to a minimally invasive surgery that helps in placing a catheter at the site of the blood clot. First, surgeons remove some of the blood from the clot. Then, tPA is injected directly into the clot within the brain tissue via a catheter. Alternatively, for ischemic stroke, medicine must be allowed to work its way into the brain through an intravenous injection. As patients recover, they continue to receive tPA treatment for up to three days, and receive additional CT scans to check the clot’s dissolution. “There is a heightened risk of secondary bleeding that can occur, because that is a potential adverse effect of the medication. But when you are looking at something with morbidity and mortality rates this high, the perceived benefit for the patient far outweighs the risks associated with the treatment,” Lapointe said. “With Mrs. Myers, we had a unique opportunity to help someone where we felt as a health care team that this was the best way to go.”   Currently, the study calls for 120 patients to be treated at the nine medical centers. Myers is the 15th patient to be treated thus far. A third phase of this particular study would include nationwide, multi-hospital involvement in evaluating the treatment as a whole before moving forward with FDA approval for all hemorrhagic stroke patients to receive this type of treatment. “God has taken care of us” Within a little less than 36 hours after her stroke, Myers was enrolled in the study. Chief neurosurgical resident Pai and neurosurgery attending physician Bailey suctioned blood from the large clot in Myers’ brain tissue before injecting the clot-dissolving medication straight to the life-threatening source every eight hours. Clinicians began her study medication and proceeded to the most challenging component of the whole process—waiting.   Jacob Myers, from left, Jannia Myers, Dr. Marc Lapointe and Dr. Suhas Pai discuss her progress. During her one-month checkup, Myers was able to personally thank Pai for helping to save her life.   “They performed her surgery Wednesday, Feb. 21, and the best thing I ever did was sign the sheet of paper saying it was OK to do the procedure on her,” Jacob said. “By Friday, all her tubes were out. The doctors kept trying to prepare us; you know, telling us that for every two steps forward we might take one more back. But I knew who I was dealing with. All you have to do is tell that woman right there that she can’t do something, and she’ll show you. She’s a fighter; a survivor. Even when that tube was in her throat, I could tell she was trying to talk to me. I told her that I would make her a deal: if she got better, then she could talk as much as she wants for the rest of her life without another word from me. You know, she held out her hand to shake on it? God has a plan for her, and she hasn’t stopped talking since that tube came out.”   In mid-March during her one-month check-up visit at Rutledge Tower, Myers and Jacob discussed their amazement with her recovery, and her physicians agreed. “For the clot to be gone in 48 hours, for her to be walking with some assistance, talking, only small memory deficits, and some residual weakness on her left side one month out from her treatment, it’s incredible,” Lapointe said. “This study and patient success stories like this one stand to change the standard of care for stroke patients with intracerebral hemorrhage just a few short years down the road. The study has to be fully completed before one can draw any conclusions at this point, however.”   Just weeks after her initial surgery, Myers was in rehabilitation treatment in Orangeburg. For Myers and Jacob, more proof that miracles do happen. “God is in control, and I’m improving every day,” she said. “Since I’ve been recovering, we’ve gone to church so I could testify about my experience and to remind everyone to take care of the body that God has given them.”   “This has brought us closer,” Jacob said of his wife, with whom he celebrated a 30th wedding anniversary April 5. “I’m going to take care of my wife. It’s not like we didn’t know that we weren’t doing our best to take care of ourselves, but this experience has enlightened us. It’s made me, us, stronger. We saw a film in rehab that talked about the recovery period and how it can break up families, but I believe our vows said ‘in sickness and in health, for better or for worse,’ so that’s what we do. She’s my better half.” Returning the squeeze of her husband’s hand, Myers said, “I know you’re mine.” Myers’ case highlights bigger issues Myers’ physicians and clinical pharmacist have been able to narrow down what they believe caused the blood clot to form in her brain. Approximately seven days before Myers had her stroke, she stopped taking her blood pressure medicine. Unable to afford her medication, she said it literally came down to a decision that week to buy her medicine or her groceries. Both she and her husband worked prior to her stroke, in addition to raising their 10-year-old grandson, who needs medication of his own for severe asthma, but money for their personal health care needs and medication are more of a luxury than part of the monthly budget.   The country, especially South Carolina, has millions of people who cannot afford health insurance or expensive medications needed to regulate hypertension, diabetes, and a number of other chronic conditions. The results can be disastrous, if not fatal.   Fortunately for Myers, she received revolutionary treatment that not only saved her life but will ensure her a better quality of life post-stroke. When she was discharged, she received a month’s supply of the hypertension medication  she so desperately needed to remain on the mend. But their financial situation remains the same post-stroke, and may even deteriorate further since Jacob must stay home from work to care for her during her final stages of recovery. They still couldn’t afford her hypertension medication when she arrived for her one-month follow-up visit, and the medication she’d been given upon discharge was gone. Concerned pharmacy students, Joshua Mount and Amy Perpich, and Lapointe also checked Jacob’s blood pressure and realized he was in danger of facing a fate similar to his wife because of his untreated severe hypertension and medical family history. The need for blood pressure medicine for both of them could not be ignored. Worried about letting them leave without an affordable way to pay for the medications each month figured out that day, Lapointe and the students began signing Myers and her husband up for Wal-Mart’s medication discount program and scheduled an appointment with a family doctor in Orangeburg. When they left the hospital after her check-up, both sets of medicine were waiting at the Wal-Mart in Orangeburg with a total discounted cost of $16 each month.   “Our treatment has been marvelous, an A-plus experience,” Jacob said. “What really touches me is the love, kindness and patience with how everyone has treated us. That means more than anything. We have been truly blessed,” Myers added.     Friday, June 8, 2007 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Island Publications at 849-1778, ext. 201.